ESC issues guidelines on diabetes, CVD

The European Society of Cardiology recently published a set of guidelines in collaboration with the European Association for the Study of Diabetes on diabetes, prediabetes and CVD.

The document defines diabetes as “a metabolic disorder characterized by chronic hyperglycemia resulting from defects in insulin secretion or action, or a combination of both.” Approximately 95% of diabetes is type 2, which may be detected using a noninvasive risk score and glycemia assessment. Diabetes may be detected by measuring whether fasting plasma glucose is >7 mmol/L, 2-hour post-glucose challenge is >11.1 mmol/L or HbA1c is >6.5%. This last measurement does not exclude a diagnosis of diabetes, and abnormal results for this test and post-glucose challenge should be repeated for confirmation.

Approximately half of impaired glucose tolerance cases can be prevented from progressing to diabetes with lifestyle interventions or pharmacotherapies, including alpha-glucosidase inhibitors, metformin, glitazones, insulin or angiotensin receptor blockers.

Diabetes contributes to micro- and macrovascular complications.

CV risk in diabetes may be determined using classical factors such as dyslipidemia, family history, hypertension or smoking status; glycemic status; coronary, cerebrovascular and peripheral arterial disease or HF; retinopathy, nephropathy, neuropathy; or arrhythmias, particularly AF, according to the investigators.

Patient education is key to managing diabetes. Patients are encouraged to quit smoking, eat healthy, exercise, reduce alcohol consumption and monitor BP, lipids, glucose and risk for thrombosis. Clinicians are encouraged to review the full document for specifics on dietary approaches and weight-loss goals for patients. The statement outlines goals for patients with regard to risk management: BP <140 mm Hg/85 mm Hg; LDL cholesterol <1.8 mmol/L (<70 mg/dL); HbA1c <7% (<53 mmol/mol).

Clinicians may manage diabetes using statins to control lipids; antiplatelet therapy for secondary CVD prevention; one or more glucose-lowering agents in combination to reach glycemic control; and metformin as first-line therapy for overweight or obese individuals.

Early angiography and culprit lesion revascularization may be appropriate to manage ACS. Stable CAD should be treated with CABG in cases of multivessel disease, complex coronary lesions or other instances where the myocardial area is large. For single or two-vessel disease, PCI with a drug-eluting stent is acceptable.

PCI with DES may be performed for symptom control in single- and two-vessel disease. For PAD, the investigators recommend revascularization of critical limb ischemia and symptomatic carotid artery disease.

Type 2 diabetes is a major risk factor for HF, according to the investigators. HF in diabetes is 12 times more likely to be fatal than diabetes alone. Renin-angiotensin-aldosterone system inhibitors, beta-blockers and diuretics may reduce this risk.

The authors of the guidelines encourage a multidisciplinary approach to diabetes management that includes a cardiologist, a diabetes expert, a surgeon, ophthalmologist, nephrologist and psychiatrist. Collaboration with nursing staff, dietitians, podiatrists and physiotherapy experts also is encouraged.

For more information, visit:

eurheartj.oxfordjournals.org/content/early/2013/08/29/eurheartj.eht108.full.